I. INTRODUCTION

A detailed history and physical examination are criti­cal first steps in the evaluation and treatment of every patient presenting with nasal obstruction. Nasal valve collapse is commonly overlooked and must be con­sidered in the complete evaluation of the patient with nasal obstruction. Certain elements of the history may prompt the rhinologist to give special consideration to the possibility of nasal valve collapse.

Patients may describe relief when they lift the soft tissues of the cheek (and thereby the lateral soft tissues of the nose)—which is known as "the Cottle sign." Also, some patients find relief from prosthetic devices such as the BreatheRite Strips, nasal stents, and other devices that lateralize the nasal soft tis­sues. This history may suggest the nasal valve as a contributing factor.

A past history of rhinoplasty with gradually wors­ening nasal obstruction may be seen in patients with nasal valve collapse. Cephalic resection of the lateral crura during rhinoplasty and subsequent postopera­tive soft tissue contraction may lead to internal and/or external nasal valve compromise. Other commonly performed surgical maneuvers such as dorsal hump reduction can result in loss of support to the middle vault, with narrowing of the middle vault with internal valve collapse.

Some patients have no history of prior surgery but simply have congenitally weak nasal sidewalls or narrow nasal valves. It may be this patient category in which nasal valve collapse is most frequently overlooked.

With age, the nasal sidewalls weaken and sagging of the nasal tip, or tip ptosis, frequently occurs. This changes the nasal airflow pattern and contributes to nasal obstruction.",' These patients may have other causes of nasal obstruction such as a deviated septum and rhinitis. Although the other contributing factors may have been of longstanding nature, the gradual addition of nasal valve collapse and tip ptosis in the aging patient may result in a description of recent onset of nasal obstruction.

Physical examination of the nose begins with an external nasal examination. Evaluating the nasal skeleton from the top down assures a stepwise andcomplete examination. A narrow middle third of the nose may be an indication of internal nasal valve compromise. External nasal valve narrowing and collapse also should be recognized when present. A severely deviated caudal septum may contribute to passive narrowing at the external nasal valve, and collapse of the mobile alar sidewall may provide an active component.

Intranasal exam should be performed before and after topicalization with a vasoconstricting agent. When indicated by the patient history or by findings on anterior rhinoscopy, a nasal endoscopic examina­tion is also performed. Examination may reveal a deviated septum, polyps, turbinate hypertrophy, internal and external valve collapse, sinusitis, and other abnormalities. A CT scan may be indicated in some patients.

There are a number of surgical approaches available to treat nasal valve collapse. Selection of the appropri­ate surgical intervention depends on proper identifi ca­tion of the anatomic cause of the collapse. Alar batten grafts are especially useful in addressing nasal valve collapse caused by a weak nasal sidewall. In this report, we review the senior author's experience with the use of alar batten grafts for nasal valve collapse.

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